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Kambo Soulsong

Soulsong Holistic Arts LLC

 

 

 

 



NOTICE: A signed waiver is required for EACH DAY you participate in ceremonies with Amy Raine/Soulsong Holistic Arts LLC.

You will not be allowed to participate in any activities with Amy Raine without the signed waiver. I recognize that AMY RAINE cannot offer this activity without obtaining a release of liability.

I Agree
 

The Colorado Natural Health Consumer Protection Act requires me to disclose the following: 

Reiki, intuitive guidance, energy work, and shamanic rituals are considered to be a holistic, natural system of care and are not intended to be a substitute for allopathic medicine- namely, conventional western medicine. The use of Kambo is considered an alternative healing therapy, and is not a substitute for or intended to be medical care. Any advice offered regarding Kambo is not designed to be a diagnosis or treatment of any disease injury, or medical condition. You must consult your physician or licensed health care provider with regard to your health or any medical conditions that may affect or be impacted by Kambo. The services and information provided should not be construed by you, the client, to be a medical or other diagnosis or treatment of any disease, injury, or mental health condition.

I, Amy Raine, am not licensed, certified or registered by the State of Colorado as a health care professional, nor am I subject to licensure, certification or registration by the State of Colorado. I have been practicing energy work for over 10 years and by the School of the Holy Spirit since 1992, covering a holistic path for healing the mind, body, emotions, and spirit. My formal education includes:

*CKPI Advanced Kambo Practitioner: Shamanflora, Iquitos, Peru

*CPR/First Aid/AED Certified #010JO6Q

*Ordained Minister: Reverend Amy Elizabeth Raine - Church of Inner Light

*Certified Trauma Recovery Coach - International Association of Trauma Recovery Coaching 

*Certified Usui Reiki Practitioner, Master Level: Lisa Guyman Meditation and Healing Arts

*Certified Animal Reiki Practitioner: Lisa Powers 

*Certified Animal Communicator: Psychic Horizons Center

*Mindfulness-Based Stress Reduction Program Graduate: University of Massachusetts Medical School Center for Mindfulness

*The Featherway I & II Sacred Journey: Navajo Illuminations

*Certified Infinity Healing Facilitator

*Clairvoyant Program Graduate: Psychic Horizons Center

*Equine Specialist in Mental Health & Learning Graduate: Professional Asociation of Therapeutic Horsemanship International

*Certified Personal Trainer: American Council on Exercise

*Certified Nutrition & Wellness Specialist: American Council on Exercise

*Biblical Studies/Ministry: Calvary Bible Institute *Baptism of the Holy Spirit 1992

*BA Behavioral Medicine/Psychology: University of North Florida 1998

 

Kambo is a shamanic ritual involving the ceremonial application of the venomous secretion from the phyllomedusa bicolor frog, which contanis natural anti-inflammatory. antibiotic, antiviral, antimicrobial, antifungal, antibacterial, peptides and has purgative properties. It is traditionally used as a hunting medicine and results in a deep physical, emotional, and energetic cleanse of the mind, body, and spirit. The effects on humans include but are not limited to: nausea, sweating, vomiting, tachycardia, diarrhea, muscle contractions, blurred vision, nervous system changes, blood pressure changes, fainting, numbness, facial swelling, and other intense painful physical symptoms. Although these effects may be expected during a Kambo ceremony, I understand there is no way to eliminate the risk of serious injury or death or to anticipate the length of any physical effects (which may last beyond the ceremony itself.)

I understand that partaking in Kambo treatment exists with significant risk of serious physical injury, death, or other damages. These risks and hazards include but are not limited to: injuries arising from inadequate preparation, failing to disclose my full medical history, not disclosing any prescription or over the counter medications I am taking, not disclosing the use of recreational drugs and consumption of alcohol, and not following instructions and guidelines provided to me by my practitioner. 

It is my responsibility to vet and be certain that the Kambo Practitioner I have chosen has adequate training and experience to administer Kambo to me. I am confident Amy Raine has the ability and training required to administer Kambo safely. I understand there is no way to completely eliminate the risk of serious harm or death when choosing to work with Kambo. I understand that my decision to receive treatment from AMY RAINE and any instruction or knowledge I receive from her, is not sufficient to prepare me for the potential dangers and risks of self-dosing or applying Kambo to others. I knowingly and voluntarily assume all risks and responsibility including, but not limited to those listed in this document whether known or unknown, of injury, illness, death or damage of any kind arising from my decision to participate in a Kambo treatment or ceremony with AMY RAINE. 

I agree to abide by all of Amy Raine's rules, recommendations, both written and/or verbal directions that may be given before, during, and after my ceremony. I may not partake in a treatment/ceremony/session with Amy Raine if I am under the influence of alcohol, recreational drugs, or any other substances.

I Agree

Kambo has no known detrimental side effects when administered responsibly. There are very few people to whom Kambo SHOULD NOT be provided due to health risks. IT IS YOUR RESPONSIBILITY TO INFORM ME if you have any serious health problems. You MUST INFORM ME if you have ever had, or are currently suffering from a mental health condition (regardless of whether or not you are taking medication) as certain conditions can be a contraindication for Kambo. Exceptions are depression, PTSD, and general anxiety. 

Kambo cannot be administered if any of the the following conditions apply: 

  • Under the age of 18
  • Pregnant
  • Breast-feeding a child under the age of one year
  • Serious heart conditions including pacemaker, valve disease, bypass surgery and enlarged heart
  • Low or High blood pressure that needs controlled by medication
  • Stroke, aneurysm, or brain hemorrhage
  • Serious mental health conditions
  • Organ transplant 
  • At the end of a 2 to 3 day fast or longer
  • Currently taking chemotherapy

Please verify any possible contraindications below:

I DO NOT have any type of serious infection or disease, including HIV or Hepatitis

I Agree

I DO NOT have a fever

I Agree

I am NOT TAKING any undisclosed prescribed medications

I Agree

I AM NOT pregnant

I Agree

I DO NOT have any cardiovascular disease or conditions

I Agree

I DO NOT have an implanted port for receiving medications

I Agree

I DO NOT have high OR low blood pressure requiring medication

I Agree

I DO NOT suffer from epilepsy or seizures

I Agree

I DO NOT have gastrointestinal ulcers

I Agree

I HAVE NOT had any surgeries or fractures in the past 8 weeks

I Agree

I HAVE disclosed any mental health diagnosis or suspected condition.

I Agree
 

I DO NOT have any nervous system disorders

I Agree

I DO NOT have cancer

I Agree

I AM NOT taking chemotherapy drugs

I Agree

I DO NOT have any present infections or uncontrolled inflammation

I Agree

I DO NOT have a hernia or bowel obstruction

I Agree

I DO NOT have any undiagnosed pain

I Agree

I DO NOT have any undisclosed conditions currently being treated by an MD, psychiatrist, or any other Alternative Health Practitioner

I Agree

I DO NOT have asthma OR IF I am asthmatic, I have an inhaler and epipen with me if needed during the ceremony

I Agree

I AM NOT an insulin dependent diabetic.

I Agree
 

I HAVE NOT received an injection for SARS/COV2 within the past 6 months

I Agree

I AM NOT currently, and HAVE NOT been under the influence of any recreational drugs or alcohol in the last 3 days

I Agree

I HAVE NOT been administered Botox, Juvederm, or other aesthetic injectables (fillers or neurotoxins) within the past 14 days.

I Agree
 

I acknowledge I have consulted a physician and am physically and mentally qualified to participate in a Kambo Session/Ceremony/Treatment. I certify that I have no physical limitations or medical conditions that would impair my ability to partake in Kambo. I agree to inform Amy Raine of any conditions and they have any effect on my ability to fully and safely use Kambo so that a determination can be made as to the proper course of action and in not doing so could potentially put my life in jeopardy.

I Agree

By signing below, you agree that your Kambo practitioner Amy Raine & SoulSong Holistic Arts LLC, her agents, assistants, employees, (collectively the "PRACTITIONER") shall not have any liability to me under any theory of liability in connection with my use of Kambo or participation in any Kambo ceremony as administered by PRACTITIONER. WITHOUT LIMITING THE FOREGOING, IN NO EVENT WILL PRACTITIONER BE LIABLE FOR ANY DIRECT, INDIRECT CONSEQUENTIAL, SPECIAL, EXEMPLARY, PUNITIVE, OR INCIDENTAL DAMAGES arising from such activity. By signing this waiver, you agree to release and forever waive any and all claims or damages you may have against PRACTITIONER in connection with your use of Kambo, including, but not limited to any claims for damages based on PRACTITIONER's negligence. This agreement shall be binding up on you, your heirs, personal representatives, exectutors, and any and all successors in interest. 

I,

understand that I am fully and solely responsible for any effects that could potentially occur in connection with my use of Kambo and participation in a Kambo ceremony administered by PRACTITIONER. 

I UNDERSTAND THE USE OF KAMBO OR PARTAKING IN A KAMBO CERMONY CAN EXPOSE ME TO A HIGH RISK OF INJURY OR ACCIDENT, including physical and/or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability, death, or economic loss. these injuries our outcomes may arise from my own or PRACTITIONER'S actions, inactions, negligence, or the condition of the location or facility. I ASSUME ALL RISKS OF MY USE OF KAMBO AND PARTICIPATION IN A KAMBO CEREMONY WITH PRACTITIONONER, WHETHER KNOWN OR UNKNOWN TO ME, OF INJURY, ILLNESS, DEATH OR DAMAGE OF WHATEVER KIND, INCLUDING TRAVEL TO OR FROM SUCH ACTIVITY OR ANY EVENTS INCIDENTAL TO SUCH ACTIVITY. 

If I need medical treatment, (including ambulance or air travel) or travel to and from the Kambo ceremony, or require any other intervention as determined by Amy Raine, I agree to be financially responsible for any such costs incurred by Amy Raine or myself as a result. 

In the event that any of the foregoing provisions are held by a court of law to be invalid or unenforceable, I agree that the total liability of Amy Raine, if any, for losses or damages shall not exceed the amount paid fo her services. 

I have read this document in it's entitrety and am signing it freely. I have sought independent legal advice and/or understand the legal consequences of signing this document, including (a) releasing the PRACTITIONER from any and all liability, (b) waiving my right to sue the PRACTITIONER, and (c) assuming all risks of participating in a Kambo ceremony administered by PRACTITIONER. 

 October 30, 2025

 

 

 

 

 



First Participant's Name
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Tenth Participant's Name
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Parent or Guardian's Email Address
Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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